PAGE: 1 10/29/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: 989898 PER PROVIDER LETTER CLAIM IS PAID IN DUPLICATE. 03/24/2014 64483 1 696.00-214.26-481.74-.00.00.00.00.00 209.97-4.29-.00.00 03/24/2014 64492 1 285.00-93.57-191.43-.00.00.00.00.00 91.70-1.87-.00.00 03/24/2014 J1030 3 105.00-22.14-82.86-.00 4.43-.00.00.00 17.36-.35-.00.00 03/24/2014 J7799 1 10.00-.00 10.00-.00.00.00.00.00.00.00.00.00 TOTAL 1 1096.00-329.97-766.03-.00 4.43-.00.00.00 319.03-6.51-.00.00 4 Add payment & adjustments back on to Member s Account 09/29/2014 95909 1 295.00 135.37 159.63.00.00.00.00.00 132.66 2.71.00.00 L SQ TOTAL 1 295.00 135.37 159.63.00.00.00.00.00 132.66 2.71.00.00
PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 3 TOTAL BILLED $474.00 BALANCE CARRIED FORWARD $186.37CR COPAYMENTS $4.43CR WITHHOLD $3.80CR And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $474.00 3 CLAIMS IN PROCESS $449.00 2 TOTAL ALL CLAIMS $923.00 5 PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT
PAGE: 1 11/05/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: 989898 10/07/2014 99213 1 179.00 70.61 108.39 35.00.00.00.00.00 34.90.71.00.00 L SQ 3 TOTAL 1 179.00 70.61 108.39 35.00.00.00.00.00 34.90.71.00.00
PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 1 TOTAL BILLED $179.00 TOTAL TO BE PAID $34.90 CREDIT BALANCE $186.37CR BALANCE CARRIED FORWARD $151.47CR COPAYMENTS $35.00 WITHHOLD $.71 And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $179.00 1 CLAIMS IN PROCESS $270.00 1 TOTAL ALL CLAIMS $449.00 2 PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: 1-888-847-7902 or (740)695-7902 PEIA: 1-888-847-7902 or (740)695-7902 SECURE CARE: 1-877-847-7907 or (740)695-7907 MOUNTAIN HEALTH TRUST: 1-888-613-8385 or (740)695-7904 ALL THESE CLAIMS WERE DENIED FOR A CORRECTED NPI NUMBER. You do not have to hold this voucher. These claims should be corrected and re-submitted to The Health Plan as soon as possible so they don t deny for Timely Filing.
PAGE: 1 11/12/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS DENIED *** SECURE CARE *** RENDERING NPI MISSING 10/22/2014 63047 22 1 3050.00.00.00.00.00.00.00.00.00.00.00.00 10/22/2014 63048 22 1 619.00.00.00.00.00.00.00.00.00.00.00.00 TOTAL 1 3669.00.00.00.00.00.00.00.00.00.00.00.00 NPI CLAIM CODES: 206 RENDERING NPI MISSING 10/22/2014 63047 22 AS 1 3050.00.00.00.00.00.00.00.00.00.00.00.00 10/22/2014 63048 22 AS 1 619.00.00.00.00.00.00.00.00.00.00.00.00 TOTAL 1 3669.00.00.00.00.00.00.00.00.00.00.00.00 NPI CLAIM CODES: 206 RENDERING NPI MISSING 10/29/2014 99214 1 270.00.00.00.00.00.00.00.00.00.00.00.00 TOTAL 1 270.00.00.00.00.00.00.00.00.00.00.00.00 NPI CLAIM CODES: 206
PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 3 TOTAL BILLED $7,608.00 CREDIT BALANCE $151.47CR BALANCE CARRIED FORWARD $151.47CR ACCOUNT STATUS BILLED CHARGES # CLAIMS Outstanding credit carried over and not reduced because nothing paid this time. CLAIMS PAID / DENIED $7,608.00 3 CLAIMS IN PROCESS $270.00 1 TOTAL ALL CLAIMS $7,878.00 4 PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: 1-888-847-7902 or (740)695-7902 PEIA: 1-888-847-7902 or (740)695-7902 SECURE CARE: 1-877-847-7907 or (740)695-7907 MOUNTAIN HEALTH TRUST: 1-888-613-8385 or (740)695-7904 HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT
PAGE: 1 11/19/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: 989898 10/15/2014 99214 1 270.00 104.36 165.64 35.00.00.00.00.00 67.97 1.39.00.00 L SQ 3 TOTAL 1 270.00 104.36 165.64 35.00.00.00.00.00 67.97 1.39.00.00
PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 2 TOTAL BILLED $1,710.00 TOTAL TO BE PAID $67.97 CREDIT BALANCE $151.47CR BALANCE CARRIED FORWARD $83.50CR COPAYMENTS $35.00 WITHHOLD $1.39 And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $1,710.00 2 CLAIMS IN PROCESS $269.00 1 TOTAL ALL CLAIMS $1,979.00 3 PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: 1-888-847-7902 or (740)695-7902 PEIA: 1-888-847-7902 or (740)695-7902 SECURE CARE: 1-877-847-7907 or (740)695-7907 MOUNTAIN HEALTH TRUST: 1-888-613-8385 or (740)695-7904
PAGE: 1 12/17/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ NOW IF YOU POST ALL THE DEBITS AND CREDITS, YOU WILL BALANCE OUT TO THE CHECK OR ELECTRONIC DEPOSIT AMOUNT. CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: 1976435 11/13/2014 99214 1 270.00 104.36 165.64.00.00.00.00.00 102.27 2.09.00.00 L SQ TOTAL 1 270.00 104.36 165.64.00.00.00.00.00 102.27 2.09.00.00 10/03/2014 99223 1 536.00 201.06 334.94.00.00.00.00.00 167.49 3.42.00 30.15 L SQ CLAIM CODES: 131 253 TOTAL 1 536.00 201.06 334.94.00.00.00.00.00 167.49 3.42.00 30.15 10/29/2014 99214 1 270.00 104.36 165.64.00.00.00.00.00 102.27 2.09.00.00 L SQ TOTAL 1 270.00 104.36 165.64.00.00.00.00.00 102.27 2.09.00.00 11/13/2014 99203 1 269.00 104.67 164.33 35.00.00.00.00.00 68.28 1.39.00.00 L SQ 3 TOTAL 1 269.00 104.67 164.33 35.00.00.00.00.00 68.28 1.39.00.00 CLAIMS DENIED *** SECURE CARE *** 10/22/2014 63047 22 1 3050.00.00.00.00.00.00.00.00.00.00.00.00 10/22/2014 63048 22 1 619.00.00.00.00.00.00.00.00.00.00.00.00 TOTAL 1 3669.00.00.00.00.00.00.00.00.00.00.00.00 R1 CLAIM CODES: 16 10/22/2014 63047 22 AS 1 3050.00.00.00.00.00.00.00.00.00.00.00.00 10/22/2014 63048 22 AS 1 619.00.00.00.00.00.00.00.00.00.00.00.00 TOTAL 1 3669.00.00.00.00.00.00.00.00.00.00.00.00 R1 CLAIM CODES: 16
PAGE: 4 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 6 TOTAL BILLED $8,683.00 TOTAL TO BE PAID $440.31 LESS ADVANCE $83.50CR NET PAID $356.81 COPAYMENTS $35.00 WITHHOLD $8.99 Outstanding credit has now cleared and you receive a check in this amount. ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $8,683.00 6 CLAIMS IN PROCESS $16,755.00 2 TOTAL ALL CLAIMS $25,438.00 8 PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: 1-888-847-7902 or (740)695-7902 PEIA: 1-888-847-7902 or (740)695-7902 SECURE CARE: 1-877-847-7907 or (740)695-7907 MOUNTAIN HEALTH TRUST: 1-888-613-8385 or (740)695-7904